Meet the team

Refer your child for treatment

Use the form below to refer your child for treatment. A member of our team will be in touch within 2 working days.

Your Details

Relationship to Patient:

Parent

Relative

Embassy/Referrer

Clinician

Other

Your Name:

Your Telephone number:

Your email address:

Preferred Language:

English

Arabic

Mandarin

Patient Details

Patient's Name

Patient's Date of Birth

Your address

Country of Residence

Medical Speciality or Condition (if known)

What is the purpose of your referral?

Diagnosis

Prognosis

Specific treatment

Second opinion

Other/unknown

This is the end of the basic form. Please note, in order to progress with a referral we require a medical report for the patient, therefore if you have this information available now, please click the 'provide more info' button. Alternatively press submit and one of our team will be in touch.